What are eating disorders?
Eating disorders describe a range of problems associated with eating, food and body image. Unfortunately, in our society it is common for individuals to feel unhappy about their bodies and to be dieting or worrying about food. When these problems are extreme or interfere with an individual's normal activities and quality of life, these concerns are considered to be psychological disorders.
The most serious eating disorder is anorexia nervosa, which is characterised by dangerously low body weight. Bulimia nervosa is not so frequently life-threatening, but seriously affects the wellbeing of sufferers and can have serious medical complications. This condition is characterised by binge eating and subsequent behaviours that are engaged in to compensate for the binge. Many individuals suffer from other equally unhealthy and disturbing patterns of eating, which are not easily classified. These are known as Eating Disorders Not Otherwise Specified (EDNOS).
Eating disorders mainly affect females but approximately one in ten individuals with an eating disorder is male. It is difficult to accurately estimate the frequency of occurrence of eating disorders due in part to the secretive nature of the disorder. In Australia, anorexia nervosa affects approximately 0.5 per cent of females, bulimia nervosa 2-3 per cent and EDNOS 2-3 per cent.
Individuals with an eating disorder have significant problems with eating habits, weight management practices and attitudes about weight and body shape. These eating-related attitudes and behaviours have numerous negative consequences including:
- Low self-esteem, depression, shame and guilt
- Obsession and anxiety
- Interference with normal daily activities
- Alienation from self and often social withdrawal
- Physiological consequences, which are potentially life-threatening.
The key clinical feature of anorexia nervosa is the individual's deliberate goal to achieve and maintain a low body weight at which the body does not function normally. About half those with anorexia nervosa achieve this weight loss by dieting and avoiding foods. Others may achieve weight loss by a combination of dieting and use of purging behaviours, such as vomiting or use of laxatives. Excessive exercise is increasingly being used to reduce weight.
Another key feature of anorexia nervosa includes an intense and irrational fear of body fat and weight gain. In addition, individuals frequently possess a misperception of their body weight and shape to the extent that they may feel or see themselves as fat, when actually they are emaciated. A further important feature of anorexia nervosa is that sufferers believe their value as a person rests with their thinness - other aspects of personality and relationships are not important in comparison.
These key psychological features contribute to drastic weight loss and a defiant refusal to maintain a healthy weight for height and age. Food, calories, weight and weight management dominate the person's life. Often the individual becomes obsessed with eating behaviour, which can be reflected in strange eating rituals or the inability to eat in front of others. It is not uncommon for people with anorexia to collect recipes and prepare meals for family and friends but not eat the meals themselves.
There is often conflict with anyone who tries to encourage eating, and withdrawal from social situations, especially when eating may be involved.
There are potentially fatal aspects of anorexia nervosa. In the short-term, starvation may result in physical changes associated with problems such as heart complications or failure. Calcium may be lost from bones, which may result in osteoporosis in the long term.
The key feature of bulimia nervosa is the re-occurrence of uncontrolled periods of binge-eating, followed by behaviours designed to compensate for the binge. During a binge, the individual may consume large amounts of food in a rapid, automatic and powerless fashion. A sense of loss of control over eating is a key feature. The binge eating may evoke the sensation of anger and other negative feelings and creates physical discomfort and anxiety about weight gain. Thus, after a binge, the individual uses some form of compensatory behaviour to counteract the effect of the food eaten, such as extreme dieting, fasting or use of excessive exercise. The compensation may also take the form of a purging behaviour such as self-induced vomiting or laxative abuse.
Individuals who binge or purge tend to be highly critical of themselves and have very low self-esteem. They may feel ashamed of their behaviour and withdraw from social gatherings, fearing they will be found out. They may also feel helplessly trapped in this cycle. These feelings are frequently very damaging emotionally and physically, as binge eating and purging behaviours may, like anorexia nervosa, result in metabolic and hormonal changes. Individuals suffering from anorexia and bulimia nervosa share many similar attitudes towards food and weight and shape.
Both groups may have a distorted body image, an intense fear of fat, an excessive preoccupation with food and body weight, and the strong conviction that a slim body shape is absolutely crucial for selfacceptance. Unlike anorexia nervosa, those with bulimia nervosa are, by definition, a normal weight or above. A person who is a very low weight but also binge eats and purges is described as having anorexia nervosa.
Other eating related problems and eating disorders not otherwise specified (EDNOS)
In our society there are many people who experience difficulties with eating behaviours, weight issues and body image problems that can severely affect their lives. These individuals often benefit from psychological help. They may show several features associated with eating disorders but not fulfil the criteria for a complete disorder. For example, a person may not eat a very large amount of food but still engages in purging behaviours. Alternatively, a person may have experienced drastic weight loss and has a persistent drive for thinness, but does not fulfil all the diagnostic criteria for anorexia. Some research suggests that EDNOS can have the same life-threatening consequences as anorexia and therefore these disorders also require vigorous treatment.
One disorder which comes under the EDNOS category is binge eating disorder (BED). This problem is characterised by recurrent episodes of binge eating but is not followed by unhealthy compensatory behaviours. These binges are accompanied by a sense of loss of control and are associated with low self-esteem and depression and, in some cases, weight gain. As in the case of bulimia, treatments for binge eating disorder are usually very effective. Unfortunately, the shame which often accompanies bulimia nervosa and binge eating problems often prevents seeking help. However, if an eating related problem is causing distress then it is important to seek professional help.
What causes an eating disorder?
There are many suggested theories of the factors involved in the development of eating disorders, but there is no single consensus on a cause. Most research acknowledges that the development of eating disorders involves a complex set of interactions between cultural, social, family, personality and physical factors (including genetic factors).
Our culture has an unrelenting idealisation of thinness and the ‘perfect' body is synonymous with beauty and success. Research suggests that this social environment encourages dieting, and dieting predisposes an individual towards eating problems. In the case of bulimia nervosa particularly, the physiological effects of dietary restriction may trigger binge eating.
In addition, feelings of inadequacy, depression, anxiety and loneliness, as well as problematic family and personal relationships, may also contribute to the development of eating disorders. Once the pattern has started, eating disorders may become self-perpetuating. Dieting, bingeing and purging help some people to cope with painful emotions and to gain a degree of control of their lives. However, at the same time, these behaviours undermine physical health, self-esteem and a sense of competence and control. In anorexia nervosa, starvation frequently contributes to a lack of flexible thinking, which may make change difficult. In almost all cases of eating disorders the individual will possess negative core beliefs about themselves that can trigger and/or maintain the disorder.
Treating an individual with an eating disorder
Many people with eating disorders do not seek treatment for their problems. There are numerous reasons for this. In the case of anorexia nervosa, the individual may not perceive that they have a problem, or may be deeply afraid of the weight gain that will be encouraged or enforced in treatment. In bulimia nervosa, individuals may not seek help as they are ashamed and fear the stigma attached to eating disorders, they may not believe they can be helped, they may not be able to afford treatment, or appropriate treatment may not be readily available. In males, eating disorders may be overlooked because these conditions are more unusual in males.
However, finding appropriate help and treatment for eating disorders is essential - the sooner, the better. The longer abnormal eating behaviours persist, the more difficult it is to overcome the disorder and its effects on the body.
Fortunately, effective treatments for eating disorders are available. Family therapy has been shown to be especially helpful for children and adolescents with anorexia nervosa. When a person is dangerously thin, long-term treatment and/or hospitalisation may be required. As anorexia nervosa is a complex disorder, it is best treated with a team of professionals including psychiatrists, psychologists, general practitioners, dietitians, social workers and nurses. All Australian States have an eating disorder foundation that can provide valuable resources and information about treatments that are available.
Bulimia nervosa and binge eating disorder may be effectively treated. Cognitive behaviour therapy in particular is widely recognised as being effective, usually requiring regular outpatient visits over a number of months. In addition, anti-depressant medication can be very valuable in reducing the urge to binge.
Psychologists are frequently crucial sources of psychological intervention and can play a vital role in helping people with eating disorders to identify and challenge the negative beliefs about themselves that are maintaining the disorder. Psychological therapy often involves education regarding eating disorders and the influence of the social environment. It typically assists individuals to learn about their eating patterns and beliefs, and provides strategies to help change dysfunctional attitudes and behaviours. Another important element of psychological therapy includes changing attitudes towards weight and body image. Individuals can gain an understanding of factors that put them at risk of eating concerns and learn ways to manage these situations. Building self-esteem and improving self-awareness are usually vital elements of therapy for individuals with an eating disorder. Enhancing social and family functioning can also be an imperative part of recovery. To ensure that improvements are maintained, treatment also focuses on relapse prevention, providing individuals with the skills necessary to manage possible setbacks in the future.
Seeking professional assistance
An essential thing to remember is that people can and do recover from eating disorders. Finding the right professional help can be of great benefit in this process.
In collaboration with a psychologist, the help of a dietitian and a GP or psychiatrist is recommended. A dietitian is helpful to advise on diet and eating regimens, and a GP or psychiatrist may treat medical complications and monitor medication - especially anti-depressant medications if they have been prescribed. Family and friends offering support and encouragement can play an important role in the success of the treatment program.